Nokea
A patient is presenting with mild symptoms of pneumonia. The doctor diagnoses the patient with 'walking pneumonia'. From your nursing knowledge, you know this type of pneumonia is caused by what type of infectious agent?
- A. Fungi
- B. Streptococcus pneumoniae
- C. Mycoplasma pneumoniae
- D. Influenza
Correct Answer: C
Rationale: Walking pneumonia is commonly caused by Mycoplasma pneumoniae, a bacterium that leads to mild, community-acquired pneumonia. Fungi cause fungal pneumonia, Streptococcus pneumoniae causes typical bacterial pneumonia, and Influenza is a viral infection.
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The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?
- A. Fever and crepitus.
- B. Rales and hives.
- C. Dyspnea and wheezing.
- D. Normal chest shape and eupnea.
Correct Answer: C
Rationale: Asthma exacerbation causes dyspnea and wheezing (C) from bronchoconstriction. Fever/crepitus (A), rales/hives (B), and normal breathing (D) are unrelated or incorrect.
Which question is essential for the nurse to ask before administering the influenza vaccine?
- A. Have you had influenza in the last year?
- B. Did you receive pneumonia vaccine last year?
- C. Are you allergic to eggs or egg products?
- D. Do you have a history of respiratory disease?
Correct Answer: C
Rationale: Influenza vaccines are often produced using eggs, so an egg allergy must be assessed to prevent allergic reactions.
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
- A. Use a sterile tube each time and suction for 30 seconds
- B. Use sterile technique and turn the suction off as the catheter is introduced
- C. Use clean technique and suction for 10 seconds
- D. Discard the catheter at the end of every shift
Correct Answer: B
Rationale: Suctioning should use sterile technique, with suction off during insertion and applied intermittently for no more than 10 seconds to prevent hypoxia and trauma.
After administering the first puff of medication, what client action demonstrates proper use of the inhaler?
- A. The client depresses the canister a second time before exhaling.
- B. The client holds his or her breath for up to 10 seconds before exhaling.
- C. The client cleans the mouthpiece with a clean paper tissue or cloth.
- D. The client bends from the waist to increase the exhaled volume.
Correct Answer: B
Rationale: Holding the breath for up to 10 seconds after inhaling allows the medication to deposit in the lungs effectively.
You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: A,C,D,E,F
Rationale: Risk factors for tuberculosis include conditions or environments that weaken the immune system or increase exposure: diabetes , long-term care residency , incarceration , IV drug use , and HIV . Liver failure is not a direct risk factor, and being a U.S. resident is not specific enough.